Treat & Referral introduction into Irish EMS

Emergency departments (EDs) throughout Ireland are experiencing over crowding resulting in very long delays for patients that do not require admission. This may influence patients to decide to abandon seeking medical help in the early phases of an acute event. Such patients may deteriorate and subsequently require admission.

With the introduction of reconfiguration of EDs in Ireland ambulance journeys are becoming longer, resulting in a higher frequency of ‘out of area’ for ambulances. These ambulances are therefore less available to respond to emergencies in their operational area. It is anecdotally reported in EMS circles that some pragmatic practitioners suggest to patients that they may ‘refuse’ transport thus avoiding long waits in the ED. These ‘suggestions’ are made on gut feelings/experience but very often there is little or no clinical process to the decision making. Shaw et al (2006) state that patients or relatives who genuinely request ambulance attendance agree to sign a ‘refusal to travel’ form following informal advice from ambulance crews. Snooks et al (2004) identified that the line between the reluctant patient and the reluctant rescuer may be blurred, with agreement reached between the ambulance crew and the patient that transportation is not needed. Balcar (2004) concludes that published triage guidelines can be safe and effective in reducing patient volume to ED. However, studies have shown that without sufficient training, paramedics’ under-triage up to 10% of patients. A follow-up study identified that 49% 
of under-triage errors were due to paramedic misuse of the guidelines. This is attributable to the brevity of their training on treat and release.

The Pre-Hospital Emergency Care Council, following the recommendations of its Medical Advisory Group (MAG), has published clinical practice guidelines (CPGs) authorising the introduction of treat & referral (T&R) clinical care pathways into the Irish Emergency Medical Services (EMS).

Inclusion criteria for T & R:

  1. ≥ 18 years.
  2. Not pregnant.
  3. Social support available.
  4. Demonstrates capacity and willing to engage.
  5. Reliable history. 
  6. Vital signs within normal range (following care).
  7. Compliant with treatment, including own medications.
  8. Clinical status of ‘Non serious or non life threatening (following care) 

  The T&R clinical care pathways options available to paramedics and advanced paramedics will be;

  • CP1 Treat & Transport to an Emergency Department 
  • CP2 Treat&ReferralforImmediatecare 
  • CP3 Treat&Referralforfollowupcarewithin 48 hours
  • CP4 Treat&Referralto self carewithafter care instructions 

Clinical conditions identified as appropriate for T&R in the introductory phase include hypoglycaemia, isolated seizure, minor burns, toothache, epistaxis and Oleoresin Capsicum (pepper) spray.

To ensure T&R is safe and effective in the Irish setting it will be introduced incrementally as a pilot and evaluation project. The outcomes of the evavaluation will be;

Safety: Will the patient following a T&R clinical care pathway have no additional episodes within 72 hours?
Patient satisfaction: Will patients have increased satisfaction following T&R?
Efficiency: Will there be an increase in ambulance availability within its Catchment area if the ambulance does not have to transport the patient to an ED?


  1. Shaw, D et al, 2006, Are they really refusing to travel? A qualitative study of prehospital records, BioMed Contral, Emergency Medicine, 6:8.
  2. Snooks, H et al, 2004, Towards primary care for non-serious 999 callers: results of a controlled study of “Treat & refer” protocols for ambulance crews, Quality and Safety in Health Care, Dec;13(6):435-43
  3. Balcar P, 2004, Ambulance non-Transport Review, Ambulance misuse, Queen’s Health Science Journal 8,Volume 6, number 2. 

The general aim will be to develop and assess a programme in Ireland for T&R by paramedics and advanced paramedics of patients in the community following a call for emergency medical assistance.The evaluation will undertake to identify the fundamental principle that T&R is a safe and effective practice. The literature has identified that the treating and referring of a patient post hypoglycaemia as a treatment modality has little risk. This research will therefore focus on T&R ofpatients following a hypoglycaemic episode. It will also make a comparison between T&R outcomes of patients with isolated seizures and patients following a hypoglycaemic episode.
The support of paramedics and advanced paramedics during the study phase is paramount to the successful introduction of treat & referral into Ireland.